Variations in Coronary Revascularization Practices and Their Effect on Long-Term Outcomes
Rodolfo V Rocha1,2, Xuesong Wang2, Stephen E Fremes3,4
1Division of Cardiovascular Surgery Peter Munk Cardiac Centre University Health NetworkUniversity of Toronto Toronto ON Canada.
Insights
Higher ratios of percutaneous coronary interventions to coronary artery bypass grafting procedures (PCI:CABG) in hospitals correlate with increased adverse cardiac events. Hospitals without on-site cardiac surgery also show higher risks for major adverse cardiac and cerebrovascular events.
Area of Science:
- Cardiology
- Health Services Research
Background:
- The variation in hospital-level percutaneous coronary intervention to coronary artery bypass grafting (PCI:CABG) ratios is not well understood.
- The clinical outcome implications of differing PCI:CABG ratios across hospitals remain unclear.
Purpose of the Study:
- To investigate the extent of hospital variation in PCI:CABG ratios.
- To determine the association between PCI:CABG ratios and patient clinical outcomes.
Main Methods:
- A multicenter, population-based study in Ontario, Canada, analyzed 44,288 patients with severe multivessel coronary artery disease undergoing revascularization (2013-2017).
- Hospitals were stratified into low, medium, and high PCI:CABG ratio tertiles.
- Clinical outcomes were compared across tertiles, adjusting for patient characteristics and hospital capabilities.
Main Results:
- Hospitals with higher PCI:CABG ratios (medium and high tertiles) showed significantly higher rates of major adverse cardiac and cerebrovascular events compared to low PCI:CABG ratio hospitals.
- Interventional cardiologists performing diagnostic angiograms increased the likelihood of patients receiving PCI.
- Diagnostic angiography at institutions lacking cardiac surgical capabilities was linked to increased risks of major adverse cardiac and cerebrovascular events, death, and myocardial infarction.
Conclusions:
- Patients treated at hospitals with higher PCI:CABG ratios experienced worse clinical outcomes, including increased major adverse cardiac and cerebrovascular events, myocardial infarction, and repeat revascularization.
- The presence of on-site cardiac surgery was associated with improved survival and reduced major adverse cardiac and cerebrovascular events, highlighting its importance in managing complex coronary artery disease.
Abstract:
Background The degree of hospital-level variation in the ratio of percutaneous coronary interventions to coronary artery bypass grafting procedures (PCI:CABG) and the association of the PCI:CABG ratio with clinical outcome are unknown. Methods and Results In a multicenter population-based study conducted in Ontario, Canada, we identified 44 288 patients from 19 institutions who had nonemergent diagnostic angiograms indicating severe multivessel coronary artery disease (2013-2017) and underwent a coronary revascularization procedure within 90 days. Hospitals were divided into tertiles according to their adjusted PCI:CABG ratio into low (0.70-0.85, n=17 487), medium (1.01-1.17, n=15 275), and high (1.18-1.29, n=11 526) ratio institutions. Compared with low PCI:CABG ratio hospitals, hazard ratios (HRs) for major adverse cardiac and cerebrovascular events were higher at medium (HR, 1.19; 95% CI, 1.14-1.25) and high ratio (HR, 1.21; 95% CI, 1.15-1.27) hospitals during a median 3.3 (interquartile range 2.1-4.6) years follow-up. When interventional cardiologists performed the diagnostic angiogram, the odds of the patient receiving PCI was higher (odds ratio, 1.37; 95% CI, 1.23-1.52) than when it was performed by noninterventional cardiologists, after accounting for patient characteristics. Having the diagnostic angiogram at an institution without cardiac surgical capabilities was independently associated with a higher risk of major adverse cardiac and cerebrovascular events (HR, 1.07; 95% CI, 1.02-1.11), death (HR, 1.09; 95% CI, 1.02-1.18), and myocardial infarction (HR, 1.10; 95% CI, 1.03-1.17). Conclusions Patients undergoing diagnostic angiography in hospitals with higher PCI:CABG ratio had higher rates of adverse outcomes, including major adverse cardiac and cerebrovascular events, myocardial infarction, and repeat revascularization. Presence of on-site cardiac surgery was associated with better survival and lower major adverse cardiac and cerebrovascular events.
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